Impact of the Radial Artery as an Additional Arterial Conduit During In-Situ Bilateral Internal Mammary Artery Grafting: A Propensity Score-Matched Study.

BACKGROUND: Bilateral internal mammary artery (BIMA) grafting has been associated with improved long-term outcomes after CABG. We sought to evaluate the early results and long-term survival among coronary artery bypass graft patients who underwent in-situ BIMA grafting with the radial artery (RA) as an additional arterial conduit compared with those who underwent BIMA with additional saphenous vein graft (SVG). METHODS: Between 1991 and 2013, 1,750 consecutive patients with triple-vessel disease or left main plus right coronary system disease underwent primary isolated in-situ BIMA grafting with at least one internal mammary artery to the left anterior descending artery. Patients were divided into a BIMA-RA group (n = 255) and BIMA-SVG group (n = 1,495). Propensity score matching was used to create two comparable cohorts: 249 BIMA-RA patients were one-to-one-matched to 249 BIMA-SVG patients. The date of death was obtained from provincial vital statistics. The median follow-up was 8 years. RESULTS: There was no difference in operative mortality between matched BIMA-RA and BIMA-SVG (0.8% versus 0.4%, respectively; p = 0.6). Five-year, 10-year, and 15-year survival rates were 98.3%, 92.0%, and 92.0%, respectively, among BIMA-RA patients, versus 96.5%, 93.0%, and 87.0% in the matched BIMA-SVG group (log rank p = 0.44). When we stratified the BIMA-RA patients into subgroups according to the severity of target artery stenosis, late survival was also similar among the BIMA-RA subgroups matched to BIMA-SVG patients (log rank p = 0.12). CONCLUSIONS: The use of the RA as an additional arterial graft in patients undergoing coronary artery bypass graft surgery with in-situ BIMA does not prolong late survival when compared with BIMA patients who received additional SVG.

Posterior leaflet P2-P1 transposition for mitral repair in a case of infective endocarditis.

Infective endocarditis represents a pathological process associated with a high mortality. The dysfunction of cardiac valves and its consequent hemodynamic deterioration often requires urgent surgery. Tissue preservation and valve repair without a substitute material may be extremely difficult. Herein, the details are reported of a safe technique used to repair a mitral valve presenting with P1 destruction caused by pneumococcal endocarditis vegetation, associated with severe mitral regurgitation. A safe repair was achieved by performing a P2 to P1 transposition, after a subvalvular apparatus analysis, followed by annular plication and ring annuloplasty. The postoperative course was uneventful, and echocardiography at discharge showed excellent mitral valve competence. Sufficient evidence was provided to demonstrate that, in these cases, it is better to repair than to replace. Hence, the present technique should be considered, whenever possible, for mitral valve surgical repair in order to avoid substitute interposition in cases of infective endocarditis.

Extracorporeal membrane oxygenation support for abdominal aortic aneurysms surgery in high-risk patients.

Surgical treatment of an abdominal aortic aneurysm in patients with a heart disease is risky. Aortic cross-clamping is featured by important consequences on cardiac, renal and gastrointestinal functions. Endovascular aortic repair is considered to be the gold standard in patients with severe comorbidities. However, in the case of unsuccessful endovascular treatment, surgery can be reconsidered with the use of extracorporeal membrane oxygenation, which seems to be a new tool for the management of cardiac and gastrointestinal events ensuring better post-operative outcomes.

Preoperative cardiac troponin I to assess midterm risks of coronary bypass grafting operations in patients with recent myocardial infarction.

BACKGROUND: The optimal timing for coronary artery bypass grafting (CABG) in patients with recent acute myocardial infarction (AMI) is unclear. Cardiac troponin I (cTnI) is a widely accepted biomarker of myocardial damage. The objective of this study was to determine whether preoperative cTnI values could be used to determine risk stratification for CABG operations in patients with recent AMI. METHODS: Evaluated were 184 patients who sustained an AMI within 21 days of undergoing nonurgent CABG operations. They were divided into two groups according to their preoperative cTnI values: 117 patients with cTnI of 0.15 ng/mL or less and 67 with cTnI exceeding 0.15 ng/mL. Associations between study variables and events were assessed with logistic regression modelling. Time from AMI to operation was evaluated to define preoperative cTnI variation. RESULTS: Values of cTnI tended to decrease when the interval between AMI and the operation increased. Preoperative cTnI values were significantly associated with a higher incidence of major postoperative complications (low cardiac output syndrome, intraaortic balloon pump necessity, mechanical ventilation >72 hours, acute renal failure, in-hospital mortality). Perioperative myocardial damage was more pronounced in patients with cTnI exceeding 0.15 ng/mL. Multivariate analyses revealed cTnI exceeding 0.15 ng/mL was an independent predictor for 6-month mortality (odds ratio, 3.7; p = 0.043). CONCLUSIONS: Preoperative cTnI exceeding 0.15 ng/mL in patients with recent AMI undergoing CABG is associated with higher postoperative myocardial damage and is a strong determinant of postoperative morbidity and mortality within the 6-month period.

Antithrombin after cardiac surgery: implications on short and mid-term outcome.

BACKGROUND: Antithrombin (AT) drop during cardiac surgery has been described. The causes and the effects of this phenomenon are not clear. The objective of the study is to evaluate the relationship of AT postoperative values on short and mid-term outcome after cardiac surgery. METHODS: Between January and June 2005, 405 patients, who underwent cardiac operations at our Institution had AT values available preoperatively and postoperatively. Using Receiver Operating Characteristic curves, a cut-off equal to 63.7% for ICU-arrival AT was chosen in order to divide the entire population in two groups (117 patients with ICU-arrival AT < 63.7%, Low AT group, and 288 patients with ICU-arrival AT > or = 63.7%, High AT group). Objective of the study was to evaluate the predictive role of ICU-arrival AT < 63.7% on in-hospital mortality and morbidity and on 18 months follow-up after cardiac surgery. RESULTS: ICU-arrival AT was significantly lower than preoperative AT (90.7 +/- 16.3% vs. 71.2 +/- 15.1%, P < 0.0001). Patients in the Low AT group were older, more often female, had a worse Euroscore and required longer CPB duration and cross clamp time. They had significantly higher preoperative and postoperative D-dimer levels. ICU arrival AT < 63.7% was not associated with increased in-hospital mortality but it was an independent risk factor for longer mechanical ventilation, need of inotropic support, excessive bleeding and blood products transfusion. ICU arrival-AT < 63.7% was associated with worse survival during 18 months follow up (92.3% vs. 85.4% in the High AT and Low AT group, respectively, P = 0.05). CONCLUSIONS: Low AT after cardiac surgery is associated with higher incidences of peri-operative complications and worse survival in the mid-term. Future studies should clarify the pathophysiologic mechanism of this findings and possible therapeutic directions.

Myocardial injury after off-pump coronary artery bypass grafting operation.

OBJECTIVE: Perioperative myocardial ischemia is less pronounced in off-pump coronary artery bypass (OPCAB) compared to on-pump coronary artery bypass; however, the threshold over which the postoperative release of cardiac troponin I (cTnI) release and creatine kinase-MB (CK-MB) after OPCAB should be considered clinically relevant is unknown. The study was designated to evaluate if perioperative myocardial damage, measured by means of postoperative release of cTnI and CK-MB, has an influence on short- and mid-term outcome after OPCAB operations. METHODS: Two hundred and sixty-one unselected patients undergoing OPCAB had cTnI and CK-MB measured preoperatively and nine times postoperatively. Postoperative peak values were evaluated and the 80th percentiles were used to segregate the population into two groups for each marker. The following cut-offs were used: 7.1 ng/dl for cTnI peak and 36.3 ng/dl for CK-MB peak. RESULTS: Patients with cTnI>7.1 ng/ml (n=51) and CK-MB>36.3 ng/ml (n=48) had a longer mechanical ventilation and ICU length of stay. Nevertheless, hospital mortality did not differ between groups. Survival after 3 years was 92.8+/-2.3% and 81.8+/-6.2 for patients with postoperative cTnI peak7.1 ng/ml, respectively (p=0.003). It was 93+/-2.2% and 80+/-6.8% for patients with CK-MB36.3 ng/ml, respectively (p=0.005). Adjusted hazard ratios for mid-term mortality were HR 2.7 (CI 1-7.6), p=0.05 for cTnI>7.1 ng/dl and HR 3.1 (CI 1-9.1), p=0.04 for CK-MB>36.3 ng/ml. CONCLUSION: Perioperative myocardial damage should not be considered an innocuous event following OPCAB operations since the survival rate over 3 years is significantly worse in patients with the highest postoperative peak release of cTnI and CK-MB.